Failure to Provide Shaving per Resident Preference While on Anticoagulant
Penalty
Summary
The facility failed to ensure that a resident was shaved according to his preferences, despite his ability to express his wishes and having intact cognition. The resident, who had multiple medical diagnoses including acute respiratory failure, heart failure, and chronic kidney disease, was admitted with an order for Plavix, a blood thinner, which placed him at risk for bleeding. The care plan specified that caution should be used when shaving and that staff should provide setup and supervision for personal hygiene, taking into account the resident's daily preferences and fluctuating abilities. During the resident's stay, there was no documented evidence that he was shaved, and interviews revealed that staff refrained from shaving him due to his anticoagulant therapy, stating that only a nurse could perform the task. The resident expressed feeling bad about not being shaved and indicated that his preference was not being met. Observation confirmed that his beard had grown to approximately a quarter inch. The facility's policy on shaving emphasized cleanliness and skin care safety, but this was not followed in the resident's case.